Health workforce governance: Processes, tools and actors towards a competent workforce for integrated health services delivery

Evaluation of the implementation of governmental policies and actions to create healthy food environments in Burkina Faso

OBJECTIVE

The creation of a healthy food environment is highly dependent on the policies that governments choose to implement. The objective of this study is to compare the level of implementation of current public policies aimed at creating healthy food environments in Burkina Faso with international good practice indicators.

DESIGN

This evaluation was carried out using the Food-EPI tool. The tool has two components (policy and infrastructure support), thirteen domains and fifty-six good practice indicators adapted to the Burkina Faso context.

SETTING

Burkina Faso.

PARTICIPANTS

Expert evaluators divided into two groups: the group of independent experts from universities, NGO and civil society and the group of experts from various government sectors.

RESULTS

Among the fifty-six indicators, it was assessed the level of implementation as 'high' for six indicators, 'medium' for twenty-four indicators, 'low' for twenty-two indicators and 'very low' for four indicators. High implementation level indicators include strong and visible political support, targets on exclusive breastfeeding and complementary feeding, strong and visible political support for actions to combat all forms of malnutrition, monitoring of exclusive breastfeeding and complementary feeding indicators, monitoring of promotion and growth surveillance programmes and coordination mechanism (national, state and local government). The indicators on menu labelling, reducing taxes on healthy foods, increasing taxes on unhealthy foods and dietary guidelines are the indicators with a 'very low' level of implementation in Burkina Faso.

CONCLUSIONS

The general results showed that there is a clear need for further improvements in policy and infrastructure support to promote healthy food environments.

Clinical staff reported knowledge on the existence of clinical governance protocols or tools utilised in selected South African hospitals

INTRODUCTION

Clinical governance outlines duties and responsibilities as well as indicators of the actions towards best possible patient outcomes. However, evidence of outcomes on clinical governance interventions is limited in South Africa. This study determined knowledge of clinical staff about the existence of clinical governance protocols/tools that are utilised in selected South African hospitals.

METHODS

A cross-sectional study conducted among randomly sampled clinical staff at Nelson Mandela Academic (NMAH), St Elizabeth in the Eastern Cape Province and, Rob Ferreira (RFH) and Themba Hospitals in the Mpumalanga Province of South Africa. A self-administered survey questionnaire was used to collect demographic information and quality improvement protocols/tools in existence at the hospitals. Data were captured in Excel spreadsheet and analysed with STATA. Knowledge was generated based on the staff member's score for the 12 questions assessed.

RESULTS

A total of 720 participants were recruited of which 377 gave consent to participate. Overall, 8.5% (32/377) of the participants got none or only one correct out of the 12 protocols/tools; and 65.5% (247/377) got between two and five correct. The median knowledge scores were 41.7% (interquartile range (IQR) = 16.7%) in three of the hospitals and 33.3% (IQR = 16.7%) at NMAH (p-value = 0.002). Factors associated with good knowledge included more than five years of experience, being a professional nurse compared to other nurses, not working at NMAH as well as being a medical doctor or pharmacist compared to other staff. Overall, 74.0% (279/377) of the respondents scored below 50%; this was 84.4% (92/109) at NMAH and 66.3% (55/83) at RFH and this difference was statistically significant (p-value = 0.017).

CONCLUSION

Despite clinical governance implementation, there was low knowledge of clinical governance protocols/tools among clinical staff. Therefore, providing more effective, relevant training workshops with an emphasis on importance of local ownership of the concept of clinical governance, by both management and clinical staff is of great importance.

The pathway to health in all policies through intersectoral collaboration on the health workforce: a scoping review

The health workforce (HWF) is a critical component of the health sector. Intersectoral/multisectoral collaboration and action is foundational to strengthening the HWF, enabling responsiveness to dynamic population health demands and supporting broader goals around social and economic development-such development underpins the need for health in all policies (HiAP). To identify what can be learned from intersectoral/multisectoral activity for HWF strengthening to advance HiAP, we carried out a scoping review. Our review included both peer-reviewed and grey literature. Search terms encompassed terminology for the HWF, intersectoral/multisectoral activities and governance or management. We carried out a framework analysis, extracting data around different aspects of HiAP implementation. With the aim of supporting action to advance HiAP, our analysis identified core recommendations for intersectoral/multisectoral collaboration for the HWF, organized as a 'pathway to HiAP'. We identified 93 documents-67 (72%) were journal articles and 26 (28%) were grey literature. Documents reflected a wide range of country and regional settings. The majority (80, 86%) were published within the past 10 years, reflecting a growing trend in publications on the topic of intersectoral/multisectoral activity for the HWF. From our review and analysis, we identified five areas in the 'pathway to HiAP': ensure robust coordination and leadership; strengthen governance and policy-making and implementation capacities; develop intersectoral/multisectoral strategies; build intersectoral/multisectoral information systems and identify transparent, resources financing and investment opportunities. Each has key practical and policy implications. Although we introduce a 'pathway', the relationship between the areas is not linear, rather, they both influence and are influenced by one another, reflecting their shared importance. Underscoring this 'pathway' is the shared recognition of the importance of intersectoral/multisectoral activity, shared vision and political will. Advancing health 'for' all policies-generating evidence about best practices to identify and maximize co-benefits across sectors-is a next milestone.

Documenting the implementation processes and effects of the data use initiatives in primary health care settings in Tanzania: A before-after mixed methods study protocol

BACKGROUND

The use of data in decision making and planning in primary health care settings is critical for improving efficiency and health outcomes for patients and communities. Implementation research can be used to fully understand the effects, context, challenges, and facilitators of data use, as well as how to scale up data use interventions. However, in the context of low resource settings, little is known about how implementation research can be employed to assess the implementation and impact of data use interventions.

METHODS

We will conduct a hybrid type 2 effectiveness-implementation study employing a mixed method controlled before and after design to measure the effects of data use interventions while simultaneously understanding the implementation of those initiatives. The controlled before and after entails measurement of the effects of the interventions at baseline and end line in a matched intervention and control health facilities using structured questionnaire to health workers (n = 440) and existing patients (n = 422) while also extracting selected health outcome variable from routine data in all participating health facilities (n = 80). The mixed methods component entails measuring the implementation outcomes (adoption, acceptability, fidelity and maintenance) and their moderators entails the integration of both quantitative and qualitative data collection, analysis, and interpretation (i.e. mixed methods) approach by using a structured questionnaire to implementers (health workers and managers) (n = 400). Experiential dimensions of implementation processes and moderators will be explored using qualitative interviews. Guided by implementation research theories and frameworks, a theory of change (TOC) is developed first to guide the evaluation of implementation processes and effects of the interventions. Descriptive and inferential statistics will be employed to analyze quantitative data whereas thematic analysis approach will be employed for qualitative data.

DISCUSSION

This study is one of the first to test the simultaneous measurement of effects and implementation processes of data use interventions in the primary health care settings. Findings will support efforts to improve quality of services by optimizing scale up and sustainability of the data use initiatives in primary health care settings.

How can intersectoral collaboration and action help improve the education, recruitment, and retention of the health and care workforce? A scoping review

Inadequate numbers, maldistribution, attrition, and inadequate skill-mix are widespread health and care workforce (HCWF) challenges. Intersectoral-inclusive of different government sectors, non-state actors, and the private sector-collaboration and action are foundational to the development of a responsive and sustainable HCWF. This review presents evidence on how to work across sectors to educate, recruit, and retain a sustainable HCWF, highlighting examples of the benefits and challenges of intersectoral collaboration. We carried out a scoping review of scientific and grey literature with inclusion criteria around intersectoral governance and mechanisms for the HCWF. A framework analysis to identify and collate factors linked to the education, recruitment, and retention of the HCWF was carried out. Fifty-six documents were included. We identified a wide array of recommendations for intersectoral activity to support the education, recruitment, and retention of the HCWF. For HCWF education: formalise intersectoral decision-making bodies; align HCWF education with population health needs; expand training capacity; engage and regulate private sector training; seek international training opportunities and support; and innovate in training by leveraging digital technologies. For HCWF recruitment: ensure there is intersectoral clarity and cooperation; ensure bilateral agreements are ethical; carry out data-informed recruitment; and learn from COVID-19 about mobilising the domestic workforce. For HCWF retention: innovate around available staff, especially where staff are scarce; improve working and employment conditions; and engage the private sector. Political will and commensurate investment must underscore any intersectoral collaboration for the HCWF.

Successes, weaknesses, and recommendations to strengthen primary health care: a scoping review

BACKGROUND

Primary health care (PHC) is a roadmap for achieving universal health coverage (UHC). There were several fragmented and inconclusive pieces of evidence needed to be synthesized. Hence, we synthesized evidence to fully understand the successes, weaknesses, effective strategies, and barriers of PHC.

METHODS

We followed the PRISMA extension for scoping reviews checklist. Qualitative, quantitative, or mixed-approach studies were included. The result synthesis is in a realistic approach with identifying which strategies and challenges existed at which country, in what context and why it happens.

RESULTS

A total of 10,556 articles were found. Of these, 134 articles were included for the final synthesis. Most studies (86 articles) were quantitative followed by qualitative (26 articles), and others (16 review and 6 mixed methods). Countries sought varying degrees of success and weakness. Strengths of PHC include less costly community health workers services, increased health care coverage and improved health outcomes. Declined continuity of care, less comprehensive in specialized care settings and ineffective reform were weaknesses in some countries. There were effective strategies: leadership, financial system, 'Diagonal investment', adequate health workforce, expanding PHC institutions, after-hour services, telephone appointment, contracting with non-governmental partners, a 'Scheduling Model', a strong referral system and measurement tools. On the other hand, high health care cost, client's bad perception of health care, inadequate health workers, language problem and lack of quality of circle were barriers.

CONCLUSIONS

There was heterogeneous progress towards PHC vision. A country with a higher UHC effective service coverage index does not reflect its effectiveness in all aspects of PHC. Continuing monitoring and evaluation of PHC system, subsidies to the poor, and training and recruiting an adequate health workforce will keep PHC progress on track. The results of this review can be used as a guide for future research in selecting exploratory and outcome parameters.

Health workforce governance and professions: a re-analysis of New Zealand's primary care workforce policy actors

BACKGROUND

This article contributes to the health workforce planning literature by exploring the dynamics of health professions in New Zealand's Primary Care sector and deriving broad lessons for an international audience. Professions tend influence health policy and governance decisions and practices to retain their place, status and influence. Therefore, understanding their power dynamics and the positions that they have on workforce policies and issues assists workforce governance or health system reform plans.

METHODS

Using the infrequently reported health workforce policy tool, actor analysis, a reanalysis of previously collected data is undertaken using an actor-based framework for the study of professionalism. Two models were developed, (1) the framework's original four-actor model and (2) a five-actor model for the comparison of the Medical and Nurse professions. Existing workforce actor data were reclassified, formatted, and entered into actor analysis software to reveal the professions' relative power, inter-relationships and strategic workforce issue positions.

RESULTS

In the four-actor model, the Organised user actor is found to be most influential, while the others are found to be dependent. In the five-actor model, the Medical and Nurse professions are individually more influential than their combined position in the four-actor model. Practicing professionals and Organised user actors have strong converging inter-relationships over workforce issues in both models, though in the five-actor model, the Nurse profession has weaker coherency than the Medical profession. The Medical and Nurse professions are found to be in opposition over the workforce issues labelled divisive.

CONCLUSIONS

These results reflect the professions' potential to influence New Zealand's Primary Care sector, indicating their power and influence over a range of policy and reform measures. As such, the four lessons that are derived from the case indicate to policy makers that they should be aware of situational contexts and actor power, take care when encountering divisive issues and try to achieve broad-based support for proposed policies.

Establishing an Observatory on Human Resources for Health (HRH) in Iran: A Qualitative Case Study

Background: Many countries face critical challenges due to shortage and maldistribution of human resources for health (HRH). An HRH observatory can be used as a mechanism to monitor HRH issues and facilitate evidence-based decision-making. This study aims to identify the essential elements of an HRH observatory for Iran. Methods: This qualitative study was conducted through semi-structured interviews with 30 key informants over two months since May 2019. Purposeful and snowball sampling methods were used. Each interview lasted a minimum of 60 min. Data analysis was performed using the content analysis approach. Results: The essential elements for integrating HRH information were categorized into the following themes: organizational structure, partnership, prerequisites for implementing HRH observatory, data management, and evidence-informed policymaking. Our results propose a national HRH observatory for Iran consisting of steering, technical and research boards, and also stakeholders' and research networks under the governance of the ministry of health and medical education (MOHME). It is required to make a comprehensive plan in several steps and arrangements based on the country's situation. The stakeholder's network was identified based on their role in HRH development and production of information and evidence. The main aim of the HRH observatory considers monitoring trends in patterns of the HRH for evidence-based decision-making and policy development. Our results propose an evidence development network consisting of a national HRH Research Center (HRHRC) and a cooperative network formed by several medical universities. Conclusion: We provide a comprehensive approach to establishing a national HRH observatory. We consider the HRH observatory as a cooperative initiative among key stakeholders to produce knowledge in order to improve human resource policymaking. The proposed HRH observatory model emphasizes networking and stakeholder involvement.

Evaluation and prioritisation of actions on food environments to address the double burden of malnutrition in Senegal: perspectives from a national expert panel

OBJECTIVE

To evaluate the extent of implementation of public policies aimed at creating healthy eating environments in Senegal compared to international best practice and identity priority actions to address the double burden of malnutrition.

DESIGN

The Healthy Food Environment Policy Index (Food-EPI) was used by a local expert panel to assess the level of implementation of forty-three good practice policy and infrastructure support indicators against international best practices using a Likert scale and identify priority actions to address the double burden of malnutrition in Senegal.

SETTING

Senegal, West Africa.

PARTICIPANTS

A national group of independent experts from academia, civil society, non-governmental organisations and United Nations bodies (n =15) and a group of government experts from various ministries (n =16) participated in the study.

RESULTS

Implementation of most indicators aimed at creating healthy eating environments were rated as 'low' compared to best practice (31 on 43, or 72 %). The Gwet AC2 inter-rater reliability was good at 0·75 (95 % CI 0·70, 0·80). In a prioritisation workshop, experts identified forty-five actions, prioritising ten as relatively most feasible and important and relatively most effective to reduce the double burden of malnutrition in Senegal (e.g. develop and implement regional school menus based on local products (expand to fourteen regions) and measure the extent of the promotion of unhealthy foods to children).

CONCLUSIONS

Significant efforts remain to be made by Senegal to improve food environments. This project allowed to establish an agenda of priority actions for the government to transform food environments in Senegal to tackle the double burden of malnutrition.

Stakeholders' Perception of the Palestinian Health Workforce Accreditation and Regulation System: A Focus on Conceptualization, Influencing Factors and Barriers, and the Way Forward

The Health Workforce Accreditation and Regulation (HWAR) is a key function of the health system and is the subject of increasing global attention. This study provides an assessment of the factors affecting the Palestinian HWAR system, identifies existing gaps and offers actionable improvement solutions. Data were collected during October and November 2019 in twenty-two semi-structured in-depth interviews conducted with experts, academics, leaders, and policymakers purposely selected from government, academia, and non-governmental organizations. The overall perceptions towards HWAR were inconsistent. The absence of a consolidated HWAR system has led to a lack of communication between actors. Environmental factors also affect HWAR in Palestine. The study highlighted the consensus on addressing further development of HWAR and the subsequent advantages of this enhancement. The current HWAR practices were found to be based on personal initiatives rather than on a systematic evidence-based approach. The need to strengthen law enforcement was raised by numerous participants. Additional challenges were identified, including the lack of knowledge exchange and salary adjustments. HWAR in Palestine needs to be strengthened on the national, institutional, and individual levels through clear and standardized operating processes. All relevant stakeholders should work together through an integrated national accreditation and regulation system.

Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health

BACKGROUND

A cohesive and strategic governance approach is needed to improve the health workforce (HW). To achieve this, the WHO Global Strategy on Human Resources for Health (HRH) promotes mechanisms to coordinate HRH stakeholders, HRH structures and capacity within the health sector to support the development and implementation of a comprehensive HW agenda and regular reporting through WHO's National Health Workforce Accounts (NHWA).

METHODS

Using an adapted HRH governance framework for guidance and analysis, we explored the existence and operation of HRH coordination mechanisms and HRH structures in Malawi, Nepal, Sudan and additionally from a global perspective through 28 key informant interviews and a review of 165 documents.

RESULTS

A unified approach is needed for the coordination of stakeholders who support the timely development and oversight of an appropriate costed HRH strategy subsequently implemented and monitored by an HRH unit. Multiple HRH stakeholder coordination mechanisms co-exist, but the broader, embedded mechanisms seemed more likely to support and sustain a comprehensive intersectoral HW agenda. Including all stakeholders is challenging and the private sector and civil society were noted for their absence. The credibility of coordination mechanisms increases participation. Factors contributing to credibility included: high-level leadership, organisational support and the generation and availability of timely HRH data and clear ownership by the ministry of health. HRH units were identified in two study countries and were reported to exist in many countries, but were not necessarily functional. There is a lack of specialist knowledge needed for the planning and management of the HW amongst staff in HRH units or equivalent structures, coupled with high turnover in many countries. Donor support has helped with provision of technical expertise and HRH data systems, though the benefits may not be sustained.

CONCLUSION

While is it important to monitor the existence of HRH coordination mechanisms and HRH structure through the NHWA, improved 'health workforce literacy' for both stakeholders and operational HRH staff and a deeper understanding of the operation of these functions is needed to strengthen their contribution to HW governance and ultimately, wider health goals.

Attitudes and Perceptions of Health Leaders for the Quality Enhancement of Workforce in Saudi Arabia

BACKGROUND AND AIM

Besides the unique exposure and experience of health leaders in facing challenges and overcoming them, and the relatively fewer articles relating to the perception of health leaders in workforce quality enhancement, health leadership plays a crucial role in redirecting the workforce, increasing job satisfaction, professional development, and burnout prevention. Thus, this study aimed to understand the current healthcare workforce quality and future expectations from the attitudes and perceptions of health leaders.

METHODS

A qualitative research was carried out using semi-structured interviews consisting of 24 different questions. Participants of the study were healthcare leaders from different backgrounds and governmental institutions. All interviews were recorded, transcribed, and then analyzed using thematic analysis via the N-Vivo program.

RESULTS

Eleven participants were involved in the study, with one female and ten males. A thematic analysis and N-Vivo program yielded 5 main themes: (1) workforce competency, (2) health transformation, (3) leadership, (4) workforce planning, and (5) healthcare quality, with 22 emerging sub-themes. Moreover, participants responded with different attitudes and perceptions.

CONCLUSION

Health leaders are satisfied with the current direction of workforce competency and planning, yet fragmentation of the system and poor accessibility may need further enhancement. Furthermore, misutilization of services and the uncertainty of the future and talent pool are potential barriers for capability building. Moreover, with the existing gap in the workforce, health leaders believe that privatization and corporatization may have a positive effect. Aside from that, Saudization with the current plan of having a minimum standard of accepting non-Saudis in certain areas might benefit in maintaining competition and enriching experience. However, catching up with further research in healthcare quality in Saudi Arabia is needed because of the ongoing health transformation.

Towards an Integrated Healthcare System: Evolutionary Game Analysis on Competition and Cooperation Between Urban and Rural Medical Institutions in China

Background

The game of interest is the root cause of the non-cooperative competition between urban and rural medical and health institutions. The study investigates competition and cooperation among urban and rural medical institutions using the evolutionary game analysis.

Methods

With the evolutionary game model, analysis of the stable evolutionary strategies between the urban and rural medical and health facilities is carried out. A numerical simulation is performed to demonstrate the influence of various values.

Results

The result shows that the cooperation mechanism between urban and rural medical Institutions is relevant to the efficiency of rural medical institutions, government supervision, reward, and punishment mechanism.

Conclusions

Suggestions for utilizing the government's macro regulation and control capabilities, resolving conflicts of interest between urban and rural medical and health institutions is recommended. In addition, the study again advocates mobilizing the internal power of medical institutions' cooperation to promote collaboration between urban and rural medical and health institutions.

Quantity and Quality of Healthcare Professionals, Transfer Delay and In-hospital Mortality Among ST-Segment Elevation Myocardial Infarction: A Mixed-Method Cross-Sectional Study of 89 Emergency Medical Stations in China

Background

Transfer delay provokes prolongation of prehospital time, which contributes to treatment delay that endangers patients with ST-segment elevation myocardial infarction (STEMI). A key constraint in reducing transfer delay is the shortage of emergency healthcare workers. This study was to explore the influence of the quality and quantity of healthcare professionals at emergency medical stations on transfer delay and in-hospital mortality among STEMI patients.

Methods

A cross-sectional study using mixed methods was conducted at 89 emergency stations in 9 districts in China's Shenzhen province. Based on a sample of 31 hospitals, 1,255 healthcare professionals, and 3,131 patients with STEMI, a generalized linear model was used to explore the associations between the quality and quantity of healthcare professionals and transfer delay and in-hospital mortality among STEMI patients. Qualitative data were collected and analyzed to explore the reasons for the lack of qualified healthcare professionals at emergency medical stations.

Results

The analysis of the quantity of healthcare professionals showed that an increase of one physician per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 5.087 min (95% CI −6.722, −3.452; P < 0.001). An increase of one nurse per 100,000 individuals was associated with decreased transfer delay by 1.471 min (95% CI −2.943, 0.002; P=0.050). Analysis of the quality of healthcare professionals showed that an increase of one physician with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay for patients with STEMI by 8.508 min (95% CI −10.457, −6.558; P < 0.001). An increase of one nurse with an undergraduate degree per 100,000 individuals was associated with decreased transfer delay by 6.645 min (95% CI −8.218, −5.072; P < 0.001). Qualitative analysis illustrated that the main reasons for low satisfaction of healthcare professionals at emergency medical stations included low income, limited promotion opportunities, and poor working environment.

Conclusions

The quantity and quality of emergency healthcare professionals are key factors influencing transfer delay in STEMI patients. The government should increase the quantity of healthcare professionals at emergency medical stations, strengthen the training, and improve their performance by linking with clinical pathways to enhance job enthusiasm among emergency healthcare professionals.

Workforce Development in Integrated Care: A Scoping Review

INTRODUCTION

Integrated care aims to improve access, quality and continuity of services for ageing populations and people experiencing chronic conditions. However, the health and social care workforce is ill equipped to address complex patient care needs due to working and training in silos. This paper describes the extent and nature of the evidence on workforce development in integrated care to inform future research, policy and practice.

METHODS

A scoping review was conducted to map the key concepts and available evidence related to workforce development in integrated care.

RESULTS

Sixty-two published studies were included. Essential skills and competencies included enhancing workforce understanding across the health and social care systems, developing a deeper relationship with and empowering patients and their carers, understanding community needs, patient-centeredness, health promotion, disease prevention, interprofessional training and teamwork and being a role model. The paper also identified training models and barriers/challenges to workforce development in integrated care.

DISCUSSION AND CONCLUSION

Good-quality research on workforce development in integrated care is scarce. The literature overwhelmingly recognises that integrated care training and workforce development is required, and emerging frameworks and competencies have been developed. More knowledge is needed to implement and evaluate these frameworks, including the broader health and social care workforces within a global context. Further research needs to focus on the most effective methods for implementing these competencies.

Qualitative exploration of health system response to COVID-19 pandemic applying the WHO health systems framework: Case study of a Nigerian state

Pandemics can result in significantly high rates of morbidity and mortality with higher impact in Lower- and Middle-Income Countries like Nigeria. Health systems have an important role in a multi-sector response to pandemics, as there are already concerns that COVID-19 will significantly divert limited health care resources. This study appraised the readiness and resilience of the Nigerian health system to the COVID-19 pandemic, using Oyo State, southwest Nigeria, as a case study. This study was a cross-sectional qualitative study involving key informant and in-depth interviews. Purposive sampling was used in recruiting participants who were members of the Task Force on COVID-19 in the state and Emergency Operations Centre (EOC) members (physicians, nurses, laboratory scientists, “contact tracers”, logistic managers) and other partners. The state's health system response to COVID 19 was assessed using the WHO health systems framework. Audio recordings of the interviews done in English were transcribed and thematic analysis of these transcripts was carried out using NVIVO software. Results show that the state government responded promptly by putting in place measures to address the COVID-19 pandemic. However, the response was not adequate owing to the fact that the health system has already been weakened by various challenges like poor funding of the health system, shortage of human resources and inadequate infrastructure. These contributed to the health system's sub-optimal response to the pandemic. In order to arm the health system for adequate and appropriate response during major health disasters like pandemics, fundamental pillars of the health system-finance, human resources, information and technology, medical equipment and leadership - need to be addressed in order to have a resilient health system.

Supporting government policies to embed and expand rehabilitation in health systems in Europe: A framework for action

Investment in action is vital to confront the challenges associated with chronic diseases and disability facing European health systems. Although relevant policy responses are being increasingly developed, most of them fail to recognize the role of rehabilitation services in achieving public health and social goals. Comprehensive guidance is thus urgently needed to support rehabilitation policy development and expand access to rehabilitation care to meet population needs effectively. This paper describes a framework to guide policy action for rehabilitation in Europe. The framework was developed in collaboration with the European Academy of Rehabilitation Medicine based on a focused literature review and expert consultations. A review in PubMed and grey literature sources identified 458 references and resulted in 135 relevant documents published between 2006 and 2019. Thematic analysis of extracted information helped summarize the findings and develop the draft policy action framework. This was circulated to a wider group of experts and discussed in three workshops in 2018-2019. The framework was revised according to their feedback. The proposed framework contains 48 options for policy action organized in six domains and twelve subdomains that address several areas of health programming. The proposed framework provides a structure to understand the policy terrain related to rehabilitation in Europe and the measures required for translating aspirational political pronouncements into targeted programmatic action and tangible health and social outcomes.

Prevention of AcuTe admIssioN algorithm (PATINA): study protocol of a stepped wedge randomized controlled trial

Background

The challenges imposed by ageing populations will confront health care systems in the years to come. Hospital owners are concerned about the increasing number of acute admissions of older citizens and preventive measures such as integrated care models have been introduced in primary care. Yet, acute admission can be appropriate and lifesaving, but may also in itself lead to adverse health outcome, such as patient anxiety, functional loss and hospital-acquired infections. Timely identification of older citizens at increased risk of acute admission is therefore needed.

We present the protocol for the PATINA study, which aims at assessing the effect of the ‘PATINA algorithm and decision support tool’, designed to alert community nurses of older citizens showing subtle signs of declining health and at increased risk of acute admission. This paper describes the methods, design and intervention of the study.

Methods

We use a stepped-wedge cluster randomized controlled trial (SW-RCT). The PATINA algorithm and decision support tool will be implemented in 20 individual area home care teams across three Danish municipalities (Kerteminde, Odense and Svendborg). The study population includes all home care receiving community-dwelling citizens aged 65 years and above (around 6500 citizens). An algorithm based on home care use triggers an alert based on relative increase in home care use. Community nurses will use the decision support tool to systematically assess health related changes for citizens with increased risk of acute hospital admission.

The primary outcome is acute admission. Secondary outcomes are readmissions, preventable admissions, death, and costs of health care utilization. Barriers and facilitators for community nurse’s acceptance and use of the algorithm will be explored too.

Discussion

This ‘PATINA algorithm and decision support tool’ is expected to positively influence the care for older community-dwelling citizens, by improving nurses’ awareness of citizens at increased risk, and by supporting their clinical decision-making. This may increase preventive measures in primary care and reduce use of secondary health care. Further, the study will increase our knowledge of barriers and facilitators to implementing algorithms and decision support in a community care setup.

Trial registration

ClinicalTrials.gov, identifier: NCT04398797. Registered 13 May 2020.

Governance in health workforce: how do we improve on the concept? A network-based, stakeholder-driven approach

BACKGROUND

Health workforce governance has been proposed as key to improving health services delivery, yet few studies have examined the conceptualisation of health workforce governance in detail and exploration in literature remains limited.

METHODS

A literature review using PubMed, Google Scholar and grey literature search was conducted to map out the current conceptualisation of health workforce governance. We identified all published literature relating to governance in health workforce since 2000 and analysed them on two fronts: the broad definition of governance, and the operationalisation of broad definition into key dimensions of governance.

RESULTS

Existing literature adopts governance concepts established in health literature and does not adapt understanding to the health workforce context. Definitions are largely quoted from health literature whilst dimensions are focused around the sub-functions of governance which emphasise operationalising governance practices over further conceptualisation. Two sub-functions are identified as essential to the governance process: stakeholder participation and strategic direction.

CONCLUSIONS

Although governance in health systems has gained increasing attention, governance in health workforce remains poorly conceptualised in literature. We propose an improved conceptualisation in the form of a stakeholder-driven network governance model with the national government as a strong steward against vested stakeholder interests. Further research is needed to explore and develop on the conceptual thinking behind health workforce governance.

Health workforce planning under conditions of uncertainty: identifying supportive integrated care policies using scenario analysis

Purpose

Integrated care presents health workforce planners with significant uncertainty. This results from: (1) these workforces are likely in the future to be different from the present, (2) integrated care's variable definitions and (3) workforce policy and planning is not familiar with addressing such challenges. One means to deal with uncertainty is scenario analysis. In this study we reveal some integration-supportive workforce governance and planning policies that were derived from the application of scenario analysis.

Design/methodology/approach

Through a mixed methods design that applies content analysis, scenario construction and the policy Delphi method, we analysed a set of New Zealand's older persons health sector workforce scenarios. Developed from data gathered from workforce documents and studies, the scenarios were evaluated by a suitably qualified panel, and derived policy statements were assessed for desirability and feasibility.

Findings

One scenario was found to be most favourable, based on its broad focus, inclusion of prevention and references to patient dignity, although funding changes were indicated as necessary for its realisation. The integration-supportive policies are based on promoting network-based care models, patient-centric funding that promotes collaboration and the enhancement of interprofessional education and educator involvement.

Originality/value

Scenario analysis for policy production is rare in health workforce planning. We show how it is possible to identify policies to address an integrated care workforce's development using this method. The article provides value for planners and decision-makers by identifying the pros and cons of future situations and offers guidance on how to reduce uncertainty through policy rehearsal and reflection.

Drivers for emigration among healthcare professionals: Testing an analytical model in a primary healthcare setting

This paper aims to contribute to the discussion on health workforce migration, notably by testing an analytical model of the individual drivers for a professional to decide to emigrate. A large database was obtained from all primary health care units on mainland Portugal. A professional satisfaction survey was conducted and information on social-economic, labour and job satisfaction characteristics, including burnout, was obtained. Results showed that healthcare professionals who reported intention to emigrate are mostly male, young, not married, and more educated; they consider their income insufficient for their needs, and show higher levels of burnout at work and professional dissatisfaction. This profile is slightly different for GPs and nurses. The results obtained contribute to the discussion on what motivates primary health care professionals, including GPs and nurses, to emigrate. They also provide insight into the design of policy measures that may mitigate the intention of these healthcare professionals in general to emigrate.

Rethinking workforce planning for integrated care: using scenario analysis to facilitate policy development

BACKGROUND

A goal of health workforce planning is to have the most appropriate workforce available to meet prevailing needs. However, this is a difficult task when considering integrated care, as future workforces may require different numbers, roles and skill mixes than those at present. With this uncertainty and large variations in what constitutes integrated care, current health workforce policy and planning processes are poorly placed to respond. In order to address this issue, we present a scenario-based workforce planning approach.

METHODS

We propose a novel mixed methods design, incorporating content analysis, scenario methods and scenario analysis through the use of a policy Delphi. The design prescribes that data be gathered from workforce documents and studies that are used to develop scenarios, which are then assessed by a panel of suitably qualified people. Assessment consists of evaluating scenario desirability, feasibility and validity and includes a process for indicating policy development opportunities.

RESULTS

We confirmed our method using data from New Zealand's Older Persons Health sector and its workforce. Three scenarios resulted, one that reflects a normative direction and two alternatives that reflect key sector workforce drivers and trends. One of these, based on alternative assumptions, was found to be more desirable by the policy Delphi panel. The panel also found a number of favourable policy proposals.

CONCLUSIONS

The method shows that through applying techniques that have been developed to accommodate uncertainty, health workforce planning can benefit when confronting issues associated with integrated care. The method contributes to overcoming significant weaknesses of present health workforce planning approaches by identifying a wider range of plausible futures and thematic kernels for policy development. The use of scenarios provides a means to contemplate future situations and provides opportunities for policy rehearsal and reflection.

Hospital Volunteering Experiences Suggest that New Policies are Needed to Promote their Integration in Daily Care: Findings from a Qualitative Study

OBJECTIVE

To explore Hospital Volunteers' (HVs) motivations and experiences, as well as the strategies they adopt to overcome challenging situations during volunteering and the needs they perceive.

METHODS

Eleven Italian HVs were purposively approached between January and July 2016, using face-to-face semi-structured interviews. The interviews were audio-recorded, transcribed verbatim and analysed using the descriptive phenomenological approach.

RESULTS

Hospital volunteering emerged as a complex experience characterised by five themes: (a) becoming a volunteer; (b) developing skills; (c) experiencing conflicting emotions; (d) overcoming role difficulties by enacting different resources and strategies; and (e) addressing emerging needs.

CONCLUSIONS

According to the findings, hospital policies aimed at promoting volunteer integration in daily care are needed and should be based on (a) a shared vision between the hospital and the volunteer associations regarding the HVs' role and skills; (b) the development of integrated models of care combining different workforces (i.e. professionals and volunteer staff); (c) appropriate training of HVs at baseline; (d) individualised continuous education pathways aimed at supporting HVs both emotionally and in the development of the required skills; and (e) tailored education that is directed to health-care staff aimed at helping them to value the service provided by HVs.

The INFORMAS healthy food environment policy index (Food-EPI) in Mexico: An assessment of implementation gaps and priority recommendations

Mexico is one of the countries with the highest prevalence of obesity and recently declared a national epidemic of diabetes. Healthy food environments have the potential to improve the diet of the population and decrease the burden of disease. The aim of the study was to assess the efforts of the Mexican Government towards creating healthier food environments using the Healthy Food Environment Policy Index (Food-EPI). The tool was developed by the International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS). Then, it was adapted to the Latin-American context and assessed the components of policy and infrastructure support. Actors from academia, civil society, government, and food industry assessed the level of implementation of food policies compared with international best practices. Actors were classified as (1) independents from academia and civil society (n = 36), (2) government (n = 28), and (3) industry (n = 6). The indicators with the highest percentage of implementation were those related to monitoring and intelligence. Those related to food retail were rated lowest. When stratified by type of actor, the government officials rated several indicators at a higher percentage of implementation compared with independent actors. None of the indicators were rated at high implementation. Government officials and independent actors agreed upon nine priority actions to improve the food environment in Mexico. These actions have the potential to improve government commitment and advocacy efforts to create healthier food environments.

'I have no love for such people, because they leave us to suffer': a qualitative study of health workers' responses and institutional adaptations to absenteeism in rural Uganda

BACKGROUND

Achieving positive treatment outcomes and patient safety are critical goals of the healthcare system. However, this is greatly undermined by near universal health workforce absenteeism, especially in public health facilities of rural Uganda. We investigated the coping adaptations and related consequences of health workforce absenteeism in public and private not-for-profit (PNFP) health facilities of rural Uganda.

METHODS

An empirical qualitative study involving case study methodology for sampling and principles of grounded theory for data collection and analysis. Focus groups and in-depth interviews were used to interview a total of 95 healthcare workers (11 supervisors and 84 frontline workers). The NVivo V.10 QSR software package was used for data management.

RESULTS

There was tolerance of absenteeism in both the public and PNFP sectors, more so for clinicians and managers. Coping strategies varied according to the type of health facility. A majority of the PNFP participants reported emotion-focused reactions. These included unplanned work overload, stress, resulting anger directed towards coworkers and patients, shortening of consultation times and retaliatory absence. On the other hand, various cadres of public health facility participants reported ineffective problem-solving adaptations. These included altering weekly schedules, differing patient appointments, impeding absence monitoring registers, offering unnecessary patient referrals and rampant unsupervised informal task shifting from clinicians to nurses.

CONCLUSION

High levels of absenteeism attributed to clinicians and health service managers result in work overload and stress for frontline health workers, and unsupervised informal task shifting of clinical workload to nurses, who are the less clinically skilled. In resource-limited settings, the underlying causes of absenteeism and low staff morale require attention, because when left unattended, the coping responses to absenteeism can be seen to compromise the well-being of the workforce, the quality of healthcare and patients' access to care.

A call for action to establish a research agenda for building a future health workforce in Europe

The importance of a sustainable health workforce is increasingly recognised. However, the building of a future health workforce that is responsive to diverse population needs and demographic and economic change remains insufficiently understood. There is a compelling argument to be made for a comprehensive research agenda to address the questions. With a focus on Europe and taking a health systems approach, we introduce an agenda linked to the 'Health Workforce Research' section of the European Public Health Association. Six major objectives for health workforce policy were identified: (1) to develop frameworks that align health systems/governance and health workforce policy/planning, (2) to explore the effects of changing skill mixes and competencies across sectors and occupational groups, (3) to map how education and health workforce governance can be better integrated, (4) to analyse the impact of health workforce mobility on health systems, (5) to optimise the use of international/EU, national and regional health workforce data and monitoring and (6) to build capacity for policy implementation. This article highlights critical knowledge gaps that currently hamper the opportunities of effectively responding to these challenges and advising policy-makers in different health systems. Closing these knowledge gaps is therefore an important step towards future health workforce governance and policy implementation. There is an urgent need for building health workforce research as an independent, interdisciplinary and multi-professional field. This requires dedicated research funding, new academic education programmes, comparative methodology and knowledge transfer and leadership that can help countries to build a people-centred health workforce.

The Midwifery Services Framework: The process of implementation

In 2015, the International Confederation of Midwives launched the Midwifery Services Framework: a new evidence-based tool to guide countries through the process of improving their sexual, reproductive, maternal and newborn health services through strengthening and developing the midwifery workforce. The Midwifery Services Framework is aligned with key global architecture for sexual, reproductive, maternal and newborn health and human resources for health, and with the recommendations of the 2014 Lancet Series on Midwifery. This second in a series of three papers describes the process of implementing the Midwifery Services Framework: the preparatory work, what happens at each stage of implementation and who should be involved at each stage. It gives an idea of the scale of the task, and the resources that will be required to implement the Midwifery Services Framework in a given country context. The paper will be of interest to health policy-makers, development partners and professional associations in countries considering different approaches to strengthening their sexual, reproductive, maternal and newborn health services, and it will help them to decide whether and when either full or partial/staged implementation of the Midwifery Services Framework will be an appropriate initiative to address identified deficits in their specific context, given the current and projected availability of resources.

Professional groups driving change toward patient-centred care: interprofessional working in stroke rehabilitation in Denmark

BACKGROUND

Patient-centred care based on needs has been gaining momentum in health policy and the workforce. This creates new demand for interprofessional teams and redefining roles and tasks of professionals, yet little is known on how to implement new health policies more effectively. Our aim was to analyse the role and capacity of health professions in driving organisational change in interprofessional working and patient-centred care.

METHODS

A case study of the introduction of interprofessional, early discharge teams in stroke rehabilitation in Denmark was conducted with focus on day-to-day coordination of care tasks and the professional groups' interests and strategies. The study included 5 stroke teams and 17 interviews with different health professionals conducted in 2015.

RESULTS

Professional groups expressed highly positive professional interest in reorganised stroke rehabilitation concerning patients, professional practice and intersectoral relations; individual professional and collective interprofessional interests strongly coincided. The corresponding strategies were driven by a shared goal of providing needs-based care for patients. Individual professionals worked independently and on behalf of the team. There was also a degree of skills transfer as individual team members screened patients on behalf of other professional groups.

CONCLUSIONS

The study identified supportive factors and contexts of patient-centred care. This highlights capacity to improve health workforce governance through professional participation, which should be explored more systematically in a wider range of healthcare services.

The evolution of the national licensing system of health care professionals: a qualitative descriptive case study in Lao People's Democratic Republic

BACKGROUND

The introduction of a systematic framework for the licensing of health care professions, which is a crucial step in ensuring the quality of human resources for health (HRH), is still evolving in Lao People's Democraic Republic. The aim of this study was to review and document the evolution of Lao HRH policies and the development of its national licensing system.

CASE PRESENTATION

A qualitative descriptive case study methodology was applied to document and describe how Lao People's Democratic Republic laid the foundation for the development of a licensing system. The results demonstrate that Lao People's Democratic Republic is currently in the process of transitioning the focus of its HRH policies from the quantity and deployment of services to remote areas to improvements in the quality of services. The key events in the process of developing the licensing system are as follows: (1) the systematic development of relevant policies and legislation, (2) the establishment of responsible organizations and the assignment of responsible leaders, (3) the acceleration of development efforts in response to the Association of Southeast Asian Nations Mutual Recognition Arrangement for standard qualifications, (4) the strengthening of educational systems for fostering competent health care professionals, (5) the introduction of a 3-year compulsory service component in rural areas for newly recruited government servants, and (6) the introduction of a requirement to obtain a professional health care certificate to work in a private hospital. The Lao Ministry of Health (MOH) has endorsed a specific strategy for licensing to realize this system.

CONCLUSION

The need for licensing systems has increased in recent years due to regional economic integration and a shift in policy toward achieving universal health coverage. A national licensing system would be a significant milestone in health system development, helping to ensure the competency of health care professionals by means of a national examination, continuing professional development, and the revoking of licenses when appropriate.

Relationship between organizational culture and commitment of employees in health care centers in west of Iran

Introduction

Presence of committed personnel in each organization not only reduces their absenteeism, delays, and displacements but also leads to a dramatic increase in performance and efficiency of an organization, mental freshness of employees, better manifestation of noble objectives, and organizational mission as well as fulfillment of personal goals. Therefore, the purpose of this study was to determine the relationship between organizational culture and organizational commitment of employees in administrative units of health care centers in the cities of Hamedan Province based on the Denison model in 2015.

Methods

In this cross-sectional study, 177 employees in administrative units of health care centers in the cities of Hamedan Province were selected by a multistage stratified sampling method. The data collection instruments included the standardized Denison organizational culture survey and organizational commitment questionnaire by Meyer and Allen. Data were analyzed by IBM-SPSS version 21 using descriptive statistics and Pearson product-moment coefficient.

Results

Among the 12 indicators of organizational culture, the highest mean scores were assigned to empowerment (16.74), organizational learning (16.41), vision (16.4), and strategic direction (16.35); respectively. Furthermore, the indicators of capability development (14.2), core values (15.31), team orientation (15.45), and goals (15.46) received the lowest mean scores in this respect. Among the four dimensions of organizational culture, the highest mean score was related to “mission” in organizational culture and the lowest score was associated with “involvement.” Meyer and Allen’s organizational commitment model also had three components in which affective commitment in this study obtained the highest score (26.63) and continuance commitment received the lowest score (24.73). In this study, there was a significant correlation between all the components of organizational culture and organizational commitment of employees in administrative units of health care centers (p < 0.05).

Conclusion

Reflecting on all the dimensions and indicators of organizational culture can lead to an escalation of organizational commitment among employees. Furthermore, focus on factors affecting the improvement of continuance commitment can promote organizational commitment of employees in administrative units of health care centers.

Regional health workforce monitoring as governance innovation: a German model to coordinate sectoral demand, skill mix and mobility

BACKGROUND

As health workforce policy is gaining momentum, data sources and monitoring systems have significantly improved in the European Union and internationally. Yet data remain poorly connected to policy-making and implementation and often do not adequately support integrated approaches. This brings the importance of governance and the need for innovation into play.

CASE

The present case study introduces a regional health workforce monitor in the German Federal State of Rhineland-Palatinate and seeks to explore the capacity of monitoring to innovate health workforce governance. The monitor applies an approach from the European Network on Regional Labour Market Monitoring to the health workforce. The novel aspect of this model is an integrated, procedural approach that promotes a 'learning system' of governance based on three interconnected pillars: mixed methods and bottom-up data collection, strong stakeholder involvement with complex communication tools and shared decision- and policy-making. Selected empirical examples illustrate the approach and the tools focusing on two aspects: the connection between sectoral, occupational and mobility data to analyse skill/qualification mixes and the supply-demand matches and the connection between monitoring and stakeholder-driven policy.

CONCLUSION

Regional health workforce monitoring can promote effective governance in high-income countries like Germany with overall high density of health workers but maldistribution of staff and skills. The regional stakeholder networks are cost-effective and easily accessible and might therefore be appealing also to low- and middle-income countries.

Health workforce development in the European Union: A matrix for comparing trajectories of change in the professions

This article assesses professional development trajectories in top-, middle- and basic-level health workforce groups (doctors, nurses, care assistants) in different European Union countries using available international databases. Three theoretical strands (labour market, welfare state, and professions studies) were connected to explore ideal types and to develop a matrix for comparison. With a focus on larger EU-15 countries and four different types of healthcare systems, Germany, Italy, Sweden and the United Kingdom serve as empirical test cases. The analysis draws on selected indicators from public statistics/OECD data and micro-data from the EU Labour Force Survey. Five ideal typical trajectories of professional development were identified from the literature, which served as a matrix to compare developments in the three health workforce groups. The results reveal country-specific trajectories with uneven professional development and bring opportunities for policy interventions into view. First, there is a need for integrated health labour market monitoring systems to improve data on the skills mix of the health workforce. Second, a relevant number of health workers with fixed contracts and involuntary part-time reveals an important source for better recruitment and retention strategies. Third, a general trend towards increasing numbers while worsening working conditions was identified across our country cases. This trend hits care assistants, partly also nurses, the most. The research illustrates how public data sources may serve to create new knowledge and promote more sustainable health workforce policy.